TNSAM Addiction Medicine

Data source: Tennessee Department of Health, Office of Health Statistics, Death Statistical System. Overdose deaths were defined as having underlying cause of death ICD-10 codes X40-X44 (accidental), X60-X64 (intentional suicide), X85 (intentional homicide), and Y10-Y14 (undetermined).

Nearly 1.2 million Note: Figures include cases in which medications were combined with other drugs. Source: “Opioid Drugs in Maintenance and Detoxification Treatment of Opiate Add Dispensing Restrictions for Buprenorphine Combination as used Medications,” Department of Health and Human Services, Federal Register, December 6, DrugED Visits Oxycodone146,535 Hydrocodone95,972 Methadone65,945 Fentanyl21,196 Hydromorphone17,666 Buprenorphine15,778

NAS Incidence by county, CY 2010

A.Mandatory Sign-up Pharmacy and Prescribers B.Query Database C.Pharmacies filled D.Data – 7 days to real time E.Method of Payment

 Board of Medical Examiners  Board of Nursing  Board of Pharmacy  Board of Osteopathic Examination  Board of Medical Examiners’ Committee on Physician Assistants  Board of Veterinary Medical Examiners  Board of Optometry  Board of Podiatric Medical Examiners  Board of Dentistry

Rules & Regulations 1.Establishing, Maintaining operating database 2.Access to database 3.Control dissemination of data and information 4.Sharing information with other states

 Active Licenses in January, 2013  21,019  With a TN mailing address  15,907  With a TN practice address  11,928

 Physician Assistants  1,424  OPA License  24

 Active Registered Nurses License  86,480  Advance Practice Nurses License  9,273  LPN License  30,068

 Pharmacies Active Licenses  2,368  Pharmacists Active Licenses  10,266

User Types8/12/2013 Increase from 8/05/2013 – 8/12/ /19/2013 Increase from 8/12/2013– 8/19/2013 Practitioner21, ,14244 Pharmacist6,309306,33122 Resident/Fellow1,871121,8754 Health Care Extender – Practitioner 2,981132,99312 Health Care Extender – Pharmacist Other Users (Admin, TennCare)

BUSINESS ACTIVITY SUB CODEDESCRIPTIONTN A0RETAIL PHARMACY737 A1CENTRAL FILL PHARMACY10 A3CHAIN PHARMACY908 A5ONLINE RETAIL PHARMACY0 A6ONLINE CENTRAL FILL PHARMACY0 A7ONLINE CHAIN PHARMACY0 B0HOSPITAL/CLINIC229 B1CHAIN HOSPITAL/CLINIC0 C0PRACTITIONER20,928 C1PRACTITIONER-DW/30268 C 2PRACTITIONER-MILITARY1 C3MLP-MILITARY0 C4PRACTITIONER-DW/ C5MILITARY PRACTITIONER – DW300 D0TEACHING INSTITUTION8 MAMLP-NURSE PRACTITIONER5,455 MBMLP-OPTOMETRIST831 MCMLP-PHYSICIAN ASSISTANT1,208 MDMLP-REGISTERED PHARMACIST0 DEA Numbers in TN

Number of Prescribers and Dispensers with Database Access and Actual Number Checking Data

Greater than 40 equivalents risks increase Greater than 100 equivalents 8-9 increase risk overdose

 Provider shoppers  > 4 providers in a year  Pharmacy shoppers  > 4 pharmacies in a year  High-dosage patients  > 100 morphine milligram equivalents (MME) per day average for year

37.1 million Opioid Prescription 5.2 million Patients 20,489 Provides 2419 Pharmacies 2011 TN Population 6.4 million

Risk of Unintentional Opioid-related Overdose Death by Patient Risk Factors Risk factorCases N=592 No. (%) Controls N=11,840 No. (%) AORs95% Confidence Interval Provider shopping 227 (38)513 ( 4 )5.13.2–8.1 Pharmacy shopping 145 (24)196 ( 2 )4.52.5–8.1 High dosage use 140 (24)172 ( 1 ) –20.8

 >90 days  II-IV Control Substances  Agreement Patient and Provider (No Restrictions)  Substance Abuse Risk  Urine Screens  2 year cycle renewal  Owner no criminal record or disciplinary actions related to controlled substances  Medical Director (Onsite 25% over all protocols have a substitute)  Policy and Procedure  Documentation TRG, Licensure  Certified Staff  Drug screen policy  Substance abuse Risk Tool  Q & A  Medicine Count  Patient Agreements

 Policy and Procedure (continued)  CSMD  Documents of request other providers  Infection Control  Policy Health and Safety  Safety STD  Policy for Continue of Care  Medical Records and Patient Billing  H & P Testing  Evaluations and Consults  Prescriptions objective and options  Risks vs Benefits  Log of Meds Rx  Instruction and Agreements  Periodic Reviews  Reason for Rx >72h of non malignant pain  CSMD  Records of other providers  Urine Q6 months and PRN  Records must be kept for 7 years  Payment  Must be check or credit card  Cash only for co-payment with insurance

 Chronic Pain Guidelines written by January 1, 2014  All prescribers with DEA 2 hours CME every 2 years  Prescribe 30 days at a time Schedule II-IV

By January 1, 2014 the commissioner shall develop recommended treatment guidelines for prescribing opioids, benzodiazepines, barbiturates, and carisoprodol. That can be used in the state as guide for caring for patients.

Introduction - Before initiating chronic opioid therapy (over ?? days) Screening (including TN risk model), non- opioid therapies, referral to MH, others Informed consent Women's special considerations Initiating chronic opioid therapy - Standard therapy, combination therapy Special considerations Methadone/suboxone UDS - qualitative & quantitative CSMD Documentation in decision making Follow up of therapy - UDS - qualitative & quantitative CSMD ED visits for OD What constitutes a failure of standard therapy? Referral to pain specialist Taper / discontinuation of opioids Documentation of decision making  Appendices  Screening tools  Follow up assessment tools  Pregnant women / NAS  Worker's comp  Tapering protocol  Informed consent  Sample pain contract  Proper disposal  Morphine equivalents calculator  Pediatric population special considerations  TN risk model for OD deaths  Doctor shopper risk factors  CSMD  Pharmacy Violence  Opioids short acting/long acting  Urine Drug Screens

Annual top 50 prescribers  Registered letter  Significant control substances  Number of patients  Morphine Equivalents prescribed  Department may withhold information if active case in BIV or OGC

Prescriber must respond with an explanation justifying the amounts of control substance prescribe within 15 business days.

Mitchell Mutter, MD Medical Director for Special Projects Tennessee Department of Health